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building your practice with imaging
IN THIS ISSUE • UK Vet benefits from going digital • Vet-specific imaging solutions • 10 reasons to go digital • Rad 101: Know your modalities
AND MUCH MORE!
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Marketing Radiography Services Make the most of your investment to increase profit centers and strengthen your practice
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building your practice with imaging
insidethisissue 5 Digital Imaging System Delivers Dramatic Benefits for UK Practice 8 Product Corner: Vita CR 10 Top 10 Reasons to Go Digital 11 Product Corner: TDR Detector 12 Marketing your Radiography Services 16 Rad 101: Know your Modalities 18 Getting Back to Basics
Pet owners are very focused on what to feed their animals, but sometimes forget the importance of keeping fresh water available at all times. It may be wise to remind your customers – pets need hydration just as much as people do!
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EXMOUTH, ENGLAND
Carestream digital imaging system delivers dramatic benefits for U.K. veterinary practice Enhanced image quality equips vets to offer better patient care; images are emailed for consultations on difficult cases
A veterinary practice on the coast of Southern England showcases the advanced medical care now available for beloved pets and their owners. Raddenstiles Veterinary Surgeons, of Exmouth, England, recently began using a state-of-the-art digital imaging system from Carestream Health. The practice installed a Vita CR system and Image Suite Software to deliver digital access and management of high-quality imaging studies for the 3,500 patients this practice sees each month. “Converting from film to CR delivers immediate access to exceptional quality images. And being able to digitally review, manage and store the images is much more efficient than working with film,” said Mr. Chris Ridge, B Vet Med MRCVS. “This new digital system is not only more convenient for our vets and staff, but also equips us to deliver better care for our patients.” continued on page 6
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building your practice with imaging
Mr. Ridge reports the increased visualization when compared to previous film images is significant. “We used to use mammography film to achieve the highest level of quality possible. But the visualization delivered by these digital images is a dramatic improvement. We can enlarge the image to view details in a suspicious area, and we’re able to detect and measure lesions and other anatomy much better than we could with film.”
“Dealing with film and chemicals is time consuming and expensive. The images are also cumbersome to manage and store.”
The practice produces a wide range of digital imaging exams such as joint studies for cruciate disease, hip dysplasia and degenerative spine disease. The images are also used to diagnose and evaluate cancers, in addition to a wide range of other illnesses and injuries. The practice serves mostly dogs and cats but also reptiles, birds and other animals that are kept as pets.
Images often emailed for remote consultations Another benefit of digital imaging is the mobility of images for consultation. The clinic has three veterinarians working each day, but images can be easily emailed to other veterinarians for remote viewing. “The vets in our practice have expertise in different areas, so we often consult with each other on cases. Being able to quickly and easily share digital images allows us to put all of our expertise to work for each of our patients,” Mr. Ridge explains. Like other vets, Mr. Ridge is on call when the need arises. In a recent case, a Jack Russell Terrier fell off a 150-foot seaside cliff and was rescued by the Coast Guard. The vet at the practice determined the dog had a broken hip and transmitted digital images to Mr. Ridge to see if he thought the injury could be repaired. “I looked at the images, decided we could fix the problem, and we successfully repaired the injury once the patient was stable and fit for surgery,” he notes.
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inside Electronic image sharing allows crucial collaboration with other clinicians. Today, a Jack Russell terrier who fell off a 150-foot cliff is back with his family. This was made possible by two vets, miles apart, sending images and collaborating on treatment planning.
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Implementing digital image capture and management not only enhances care, it’s also a good business decision. “Dealing with film and chemicals is timeconsuming and expensive. The images are also cumbersome to manage and store. Today we’re charging the same amount for each X-ray, but digital capture and management offers lower costs. We produce from 100 to 300 X-ray images a month, and we will quickly recover the initial investment,” Mr. Ridge reports. Raddenstiles Veterinary Surgeons is a member of CVS Group Plc, which owns 249 surgeries, six diagnostic laboratories, an online dispensary and two pet crematoria across the United Kingdom.
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A fast and easy digital solution.
These systems save time, provide great reliability and enhanced patient care.
VitaCR
product
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CARESTREAM DIRECTVIEW Vita CR Systems expedite imaging workflow by providing a fast and easy setup process, an intuitive interface that minimizes training time and default image preferences to simplify selection. The system offers quick correction of over- and underexposures, and a “smart erase” feature reduces cycle time between scans. The modular system offers easy maintenance and consistent uptime. CARESTREAM Image Suite software handles order entry; animal-image acquisition and processing with parameters for species, breeds and body parts; viewing, editing and reporting; printing and digital archiving. For more information on Carestream’s veterinary imaging solutions, visit www.carestream.com/veterinary
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The Top
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Reasons to Go Digital
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Your imaging exams will go faster and more smoothly than ever before. Your X-ray images will be displayed in a matter of seconds – as opposed to the lengthy process involved in developing and printing film. Plus, you’ll know right away if a retake is needed. This all adds up to faster diagnoses and earlier treatment.
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You’ll be working with images of superb digital quality. This can mean a higher level of confidence in your diagnoses and, potentially, an increased standard of care.
Have you been considering upgrading your practice from film-based radiography to digital imaging? There are many reasons this can be a great move, from both a business and a patient-care perspective. Here are ten of the best ones.
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No more film. Say goodbye to the storage and handling of toxic chemicals, fumes and odors, and long processing times. You gain imaging flexibility and versatility. With CARESTREAM software, you can capture both soft tissue and bone detail in the same image, eliminating the need for multiple exposures with film cassettes. Digital imaging supports increased clinical collaboration, because images can be shared electronically – quickly and easily.
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Exam images, captured digitally, can be enhanced and manipulated to aid in interpretation. You’ll save valuable floor space. Without film, there’s no need for a dedicated darkroom – you can use it for a different purpose! You’ll also reduce your storage space, because all of your images can be archived digitally. Even better, you’ll save money. Advancing technology is making the initial cost of a digital system ever more affordable. And with no consumables, you’ll enjoy a lower cost of ownership and operation over time. The transition is smooth and easy. It begins with rapid system installation. Then you’ll find that digital imaging fits right in to your existing workflow – with little-to-no disruption. An intuitive, easy-to-use interface minimizes training time – and because cassettes and detectors handle just like the film you’re using now, the process will be familiar and comfortable from day one.
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Digital imaging is state-of-the-art technology. As such, it can both differentiate your practice from the competition and enhance your professional image.
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Marketing your Radiography Services “Good medicine is good business,” or so they taught us in vet school. But we all know that it isn’t that easy or clear cut. The way you market your practice, and your investment in new technology, can make a huge difference in the number of procedures you do, and the success of your profit centers and overall practice. 12
building your practice with imaging
Upgrading from film to digital radiography is a good investment, for a variety of reasons: • – – • • • •
•
Pre-programmed matrices and image adjustment mean fewer retakes Decreased radiation exposure to pets and personnel Extended tube life No more film, film storage, or darkroom expense Easy transmission of images to radiologists for telemedicine consultation Diagnostic algorithms in the software for consistency across exposures Great quality images for marketing materials, both online (practice website, newsletter, Facebook and Pinterest pages), and printed versions, such as brochures. Even have the more interesting ones printed and framed for decoration/interest pieces in your waiting room
Upgrading from a CR system (or film) to a DR system has the added benefit of considerable time savings. Let’s explore ways for you to help your clients understand the importance of this investment and how it relates to their pets. While the word “marketing” conjures images of junk mail and infomercials, it simply refers to getting your messages to your clients. We’ll discuss marketing modalities (like newsletters, websites, Facebook pages, etc.) later – today we will start at the very root of marketing any of your services, with the conversations you have with your team and your clients. continued on page 14
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Start with your team One of the most important steps in your marketing plan should be your staff – make sure that they understand how your new technology helps your patients, and make your employees your best advocates. The new technology is exciting, and your staff will also be enthusiastic about the benefits your digital radiography offers to your patients.
can become resentful when a practice consistently has money to purchase the “latest and greatest,” but there haven't been any raises for years. And resentful staff will definitely not send the message you want.
The next step: tell your clients For most veterinarians, one of our most influential teachers (for better or worse) was our first boss once we were out of
“Successful practices invest in the best technology, and charge appropriately.”
Highlight the benefits to your patients during staff training, including: • • •
Fewer retakes for less radiation exposure Better quality images for a better diagnosis Easily transferred images – for telemedicine, for specialists, and for clients who can take them for ER/ICU care or when moving to a new area
Successful practices invest in the best technology, and charge appropriately. This includes new high-tech devices such as digital radiography and blood chemistry equipment, but it also includes staff training and compensation. Support staff 14
school. I know I learned a lot of things from mine that weren’t taught in school, and some of those lessons (including what not to do) stay with me to this day. Like lessons in other parts of life, the most powerful one I learned from him was also the simplest: "Tell your clients you do a great job." He would go on about what a great job he did with a dog spay, about how well things went in surgery, because the pet owner has no other way to relate (other than the neatness of the skin sutures). When you review pet radiographs with your clients, spend a little extra time with them – even two minutes will increase their understanding, and make a huge impression. Make sure
building your practice with imaging
that they know what a good job your staff did and how your investment in technology has made radiography an even better tool to diagnose their pet. Don't just jump straight to that liver mass! Orient the owner (most have no idea where the head or heart is or should be). Point out the fine details, and give the pet owner a chance to see how much information you really get from that image. Manipulate the contrast in front of them, and explain that you could not do that with film.
In some cases, such as in a practice brochure, space is at a premium, and you need to communicate how your radiology services can help your patients, and bring your clients peace of mind, in a short paragraph or list, alongside an easy-to-understand image with a clear caption.
It may seem silly to think of marketing a service after you've sold it, but what you are really doing is preselling your services for the next time you recommend radiographs. You are also building your own credibility at the same time, making it easier for clients to accept other recommendations.
and lets you highlight your digital radiography and its advantages without sounding "salesy."
Send the right message From Marketing 101 (you remember, one of the classes we didn’t have in vet school): it's not about you. Realize that your clients don’t really care about your extended tube life, or how it makes your life easier to lose the darkroom. They care about how it benefits them and their pets – about less radiation and how better images lead to better, faster diagnoses.
In other venues, such as your website, newsletter or Facebook posts, telling a short story to go with an image will be much more effective. This engages your reader – everyone loves a story –
As I said, we’ll cover brochures, websites, Facebook pages, newsletters, and even basic image manipulation (cropping, resizing, adding text) in upcoming issues. For now, make sure your staff is really on board, and start talking to your clients! Dr. LoSasso is a 20-year veteran of the veterinary trenches. In addition to his role as Chief of Staff of a busy emergency practice, he helps his colleagues market their services through an e-newsletter service. To learn more, visit http://newslettersforvets.com. 15
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Rad101 Know your modalities
Radiology has evolved radically since X-rays were first discovered in 1895. Today, there are three common techniques for capturing diagnostic images – but there’s often some confusion about what distinguishes them from each other and how each one works. Here’s a quick overview.
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Film-based Radiology
Computed Radiography (CR)
Digital Radiography (DR)
Here’s the oldest process and the one most people are familiar with, because it's been around for more than a century. This method passes a beam of radiation through the body part and exposes a sheet of film. The film is then processed with chemicals to create an image. Film gets the job done and can provide quality diagnostic images. But it has drawbacks as well: it's timeconsuming, requires ongoing film purchases and uses harsh chemicals with unpleasant fumes.
This technology replaces the film with a cassette containing a phosphor screen. It's exposed the same way film is, creating a latent image on the phosphor. The cassette is then inserted into a scanner that captures the analog image data, converts it to digital, and displays the new, electronic image on the monitor screen. The CR process is much faster than film, and delivers excellent image quality. It's a very affordable and effective "bridge" strategy for going from film to full DR imaging.
Today’s benchmark for imaging quality and productivity, DR eliminates CR's intermediate scanning step from the process. It uses a sophisticated “detector” that captures a fully digital image during the exposure. This is sent instantly to the viewing station. DR delivers superb images, while it speeds workflow to save time and money.
Your patients are going to love you... even more.
inside Image Suite software features a custom-designed veterinary interface. Our order-entry screens have the specific fields vets need, allowing selection of breed, species, body part and more.
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back basics getting
to
In today’s digital world, basic functions once performed by the operator are now preprogrammed. For example, your cell phone most likely has a built-in digital camera. Before you take that picture of your dog eating peanut butter, you don’t stop to set the ISO, f-stop or check the lighting. Chances are that thought never even crosses your mind. The camera is programmed to make these selections for you. In most cases, your images turn out rather well, but every once in a while, one is too light or too dark, blurry or just plain no good. When this happens, you think “oh, well,” and you delete it and take another picture. 18
But why did it fail? Quite simply, the software is only as good as the information it’s supplied. The image-processing algorithm on your phone can’t take bad data and make it good, although it will do its best. It’s often referred to as “garbage in, garbage out.” The same is true with today’s digital imaging systems. There’s a misconception that when moving from a film-based X-ray system to a digital system that image processing will make all your images great. Just like the cell phone example, the image processing is only as good as the information with which it’s supplied. Except this time, you’re supplying ionizing radiation to a patient – so you
building your practice with imaging
can’t just say “oh, well” and take another image when it doesn’t turn out the way you’d like. To ensure that your images always are of optimal quality, remember these three key points: positioning, technique and collimation. When these three conditions are satisfied, you’ll have a beautiful image every time, whether it’s through film, computed radiography (CR) or digital radiography (DR). These are the basics of image capture and they work in conjunction with each other. So let’s look at each of these in more detail.
Positioning
is the most important of the three. It’s estimated that 85% of all repeat images are due to positioning errors. Most modern X-ray systems come equipped with automatic exposure controls, also known as AECs or AEDs. It’s also sometimes referred to as phototiming. These devices are ionization chambers that measure a preset quantity of radiation and break the timing circuit when a dose sufficient to produce the desired film density has been reached. When using an AEC, it’s critical that the location of the ionization chamber be determined and the precise positioning of tissue over that location be achieved. Automatic exposure devices provide a diagnostic quality density only for structures positioned directly above the ionization chambers.1
The function of the AEC is to eliminate the need for radiographers to set an exposure time. However, they must still manually set the mA and kVp. Failure to position properly over the AEC has a big impact on exposure technique, which we’ll discuss next. And failure to position correctly over the AEC will cause the exposure to terminate prematurely, producing an image that’s underexposed, with poor image quality.
Technique,
for the purposes of this article, refers to the exposure factors of kVp, mA and mAs. Think of technique as light in a film camera. If you take a picture in low light, there’s not enough light to expose the film and the image is
“85% of all repeat images are due to positioning errors.” underexposed. If exposed to bright light, the image is overexposed. The same is true in film radiography. If the exposure techniques are too low, the film is underexposed, and if they’re too high, the film will be overexposed. But keep in mind that this not necessarily the case with digital imaging such as CR and DR. In digital imaging, the film density will remain the same, regardless of the exposure techniques, but the amount of image noise will increase or decrease, depending on the exposure techniques. Image noise presents with a mottled appearance on the film, like it was sprinkled with salt and pepper. This mottling, caused by underexposure of the image, decreases the amount of detail that can be seen in an image and may result in a misdiagnosis. An overexposed image will have less mottling but result in unnecessary radiation exposure to the patient. Too high an exposure may also cause saturation of the receptor. In this case, image information will be lost a retake will be required – with additional radiation exposure to the patient.
Collimation
or beam-limiting devices, are used to decrease the amount of unnecessary scatter radiation to the patient. By decreasing scatter radiation, you increase detail and contrast in the image.
continued on page 20
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Many modern imaging systems come equipped with automatic collimation, in which the system senses the size of the receptor being used and collimates to its outer edges. This may be acceptable when imaging a hand on an 18 x 24 cm cassette, which will fill the entire field. However, when using a larger cassette, this leaves areas of unattenuated beam, which promotes scatter production and decreased contrast in the image. The recommendation is always to collimate close to the skin line of the patient, whenever possible. When you’re using digital imaging equipment, it will also help the imageprocessing software better identify the correct region of interest for optimal image processing. Keep in mind that CR and DR receptors are more sensitive to scatter radiation than film/screen cassettes. About 50-90 percent of a radiograph’s density may result from scattered radiation, so that restriction of the primary beam requires an increase in exposure to compensate for the loss of density.2 Radiographers need to be aware of the effects that scatter radiation will have on image quality, and collimate appropriately to reduce these effects.
These basic principles are the cornerstones of high-quality, consistent imaging. Radiographers who understand and routinely apply these principles are vital to the success of any imaging facility. Modern imaging equipment has revolutionized the industry by performing many of these functions automatically, but radiographers must understand these principles, and adjust or override these features to ensure correct operation and reduce unnecessary exposure to patients. Getting back to the basics can save you time, money and aggravation by reducing repeat images, materials used and patient exposure. In other words, sometimes to move forward, it’s best to look backwards. Martin S. Pesce, B.S.R.T (R), is a Worldwide Applications Engineer, DMS Product Commercialization Team, X-ray Solutions, Carestream Health, located in Rochester, NY. 1Richard R. Carlton, M.S., R.T. (R) (CV), FAERS, Arlene M. Adler, M.Ed., R.T. (R), FAERS, Principles of Radiographic Imaging an Art and a Science, Delmar Publishers, Albany, pg. 505, 1996. 2Joseph Selman, M.D., FACR, FACP, The Fundamentals of X-Ray and Radium Physics, Charles S Thomas Publisher, Springfield, IL, pg. 387, 1994.
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